A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair.
Which intervention is most important for the nurse to include in the plan of care?
A.
Turn every 2 hours around the clock from side-to-side.<\/p>\n\n\n\n
B.
Assess skin condition and turgor for breakdown.<\/p>\n\n\n\n
C.
Record the amount of daily wound drainage.<\/p>\n\n\n\n
D.
Replace fluids IV based on intake and output.<\/p>\n\n\n\n
The Correct answer and Explanation is:<\/mark><\/strong><\/p>\n\n\n\n The correct answer is D. Replace fluids IV based on intake and output.<\/strong><\/p>\n\n\n\n In clients with severe ulcerative colitis, particularly after surgery for a fistula repair, fluid and electrolyte imbalances are a significant concern. Ulcerative colitis involves inflammation and ulceration of the colon, which can lead to excessive diarrhea, dehydration, and loss of electrolytes. Post-surgery, clients are at an even greater risk of fluid imbalance due to both surgical stress and potential fluid loss from wound drainage or continued bowel dysfunction.<\/p>\n\n\n\n Why Fluid Replacement is Critical:<\/strong><\/p>\n\n\n\n After surgery, it is common for clients to experience fluid loss through various mechanisms, including wound drainage, loss of fluids through diarrhea (if the colon is still functioning), or due to the body’s response to inflammation. Inflammatory bowel diseases like ulcerative colitis can exacerbate these issues. Ensuring proper fluid balance is crucial to avoid complications such as hypovolemia (low blood volume), which can lead to decreased organ perfusion, shock, and even organ failure.<\/p>\n\n\n\n In this scenario, replacing fluids based on the client\u2019s intake and output is the most critical intervention. The nurse must closely monitor the client\u2019s fluid intake (through IV fluids, oral intake if applicable) and output (urine, wound drainage, stool, etc.). Fluid replacement should be adjusted to match the client’s needs to prevent dehydration or fluid overload. The intake-output balance will help maintain hemodynamic stability and ensure proper perfusion to organs, promoting healing and recovery.<\/p>\n\n\n\n Other Options:<\/strong><\/p>\n\n\n\n Thus, replacing fluids based on intake and output ensures that the client maintains optimal hydration, prevents complications, and promotes recovery.<\/p>\n","protected":false},"excerpt":{"rendered":" A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair.Which intervention is most important for the nurse to include in the plan of care?A.Turn every 2 hours around the clock from side-to-side. B.Assess skin condition and turgor for […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-142305","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/142305","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=142305"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/142305\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=142305"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=142305"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=142305"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}Explanation:<\/h3>\n\n\n\n
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